Healthcare Provider Details

I. General information

NPI: 1659076123
Provider Name (Legal Business Name): DIVINE MENTAL HEALTHCARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 04/03/2023
Certification Date: 04/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 STUYVESANT AVE FL 2
UNION NJ
07083-6995
US

IV. Provider business mailing address

940 STUYVESANT AVE FL 2
UNION NJ
07083-6995
US

V. Phone/Fax

Practice location:
  • Phone: 973-223-8417
  • Fax: 908-686-9445
Mailing address:
  • Phone: 973-223-8417
  • Fax: 908-686-9445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. CHIKAODI C IBEKU
Title or Position: CEO
Credential: DNP & FNP
Phone: 973-223-8417